Surgical management of a giant right atrial myxoma.

Cardiac tumours represent around 0.2% of tumours overall, and primary cardiac tumours are even more uncommon. We report the case of a 72-year-old female with a 7 cm × 4 cm right atrial mass which was prolapsing through the tricuspid valve. The mass was resected and histological analysis confirmed a myxoma. This report describes a rare finding of a giant right atrial mxyoma and subsequent surgical management.

The paravertebral panto: it's behind you!

This case report highlights the utility of paravertebral (PV) imaging in the diagnosis of aortic dissection, the evaluation of left ventricular systolic function and drawing the distinction between pleural and pericardial effusions. In this case, less attenuation of the ultrasound beam, reduced lung viscosity due to pleural effusions and less impedance mismatch between media led to images of superior quality and high diagnostic value. This supports the use of paravertebral imaging as an adjunct to conventional echocardiography windows, particularly when conventional transthoracic imaging proves challenging. LEARNING POINTS: PV images provide superior resolution when interrogating the descending aorta and thus can reveal incidental findings such as aortic dissection.PV imaging provides clearer delineation between pericardial and pleural effusions.Additional information may be obtained from the PV window in relation to left ventricular systolic function particularly in the setting of suboptimal transthoracic image quality.

The size of juxtaluminal hypoechoic area in ultrasound images of asymptomatic carotid plaques predicts the occurrence of stroke.

OBJECTIVE: To test the hypothesis that the size of a juxtaluminal black (hypoechoic) area (JBA) in ultrasound images of asymptomatic carotid artery plaques predicts future ipsilateral ischemic stroke. METHODS: A JBA was defined as an area of pixels with a grayscale value <25 adjacent to the lumen without a visible echogenic cap after image normalization. The size of a JBA was measured in the carotid plaque images of 1121 patients with asymptomatic carotid stenosis 50% to 99% in relation to the bulb (Asymptomatic Carotid Stenosis and Risk of Stroke study); the patients were followed for up to 8 years. RESULTS: The JBA had a linear association with future stroke rate. The area under the receiver-operating characteristic curve was 0.816. Using Kaplan-Meier curves, the mean annual stroke rate was 0.4% in 706 patients with a JBA <4 mm(2), 1.4% in 171 patients with a JBA 4 to 8 mm(2), 3.2% in 46 patients with a JBA 8 to 10 mm(2), and 5% in 198 patients with a JBA >10 mm(2) (P < .001). In a Cox model with ipsilateral ischemic events (amaurosis fugax, transient ischemic attack [TIA], or stroke) as the dependent variable, the JBA (<4 mm(2), 4-8 mm(2), >8 mm(2)) was still significant after adjusting for other plaque features known to be associated with increased risk, including stenosis, grayscale median, presence of discrete white areas without acoustic shadowing indicating neovascularization, plaque area, and history of contralateral TIA or stroke. Plaque area and grayscale median were not significant. Using the significant variables (stenosis, discrete white areas without acoustic shadowing, JBA, and history of contralateral TIA or stroke), this model predicted the annual risk of stroke for each patient (range, 0.1%-10.0%). The average annual stroke risk was <1% in 734 patients, 1% to 1.9% in 94 patients, 2% to 3.9% in 134 patients, 4% to 5.9% in 125 patients, and 6% to 10% in 34 patients. CONCLUSIONS: The size of a JBA is linearly related to the risk of stroke and can be used in risk stratification models. These findings need to be confirmed in future prospective studies or in the medical arm of randomized controlled studies in the presence of optimal medical therapy. In the meantime, the JBA may be used to select asymptomatic patients at high stroke risk for carotid endarterectomy and spare patients at low risk from an unnecessary operation.

Ascending aorta thrombus adjacent to a cholesterol-rich plaque as the source of multiple emboli.

Ascending aortic thrombus causing thromboembolism in the absence of hyper-coagulable states is a rare occurrence. We present a case of a 40-year old healthy female smoker who presented with a 6-month history of three transient ischaemic attacks, hand pain and numbness despite being on dual anti-platelet therapy. Computed tomography revealed a mid-ascending aorta thrombus. She underwent ascending aorta replacement on cardiopulmonary bypass, but without the use of circulatory arrest. She recovered uneventfully. We identified a fresh thrombus adjacent to a soft, cholesterol-rich plaque as the culprit lesion. We advocate surgical excision of such lesions as the only way of removing the underlying cause of thromboembolism. In addition, rupture-prone aortic plaques may lead to a penetrating aortic ulcer or an intramural haematoma and ultimately aortic dissection.

Computerized texture analysis of carotid plaque ultrasonic images can identify unstable plaques associated with ipsilateral neurological symptoms.

We estimated the value of objective, computerized texture analysis of ultrasonic images in distinguishing carotid plaques associated with neurological ipsilateral symptoms (amaurosis fugax [AmF; n = 30], transient ischemic attack [TIA; n = 52], and stroke [n = 55]) from asymptomatic plaques (n = 51). We performed 3 case-control studies (1/symptom with asymptomatic plaques as control). On logistic regression, AmF was independently associated with severity of stenosis, percentage of pixels with gray levels 0 to 10 (PPCS1; measure of echolucency), and spatial gray level dependence matrices (SGLDM) information measure of correlation (IMC-1; texture); TIAs with PPCS1 (echolucency), SGLDM correlation, and skewness (both texture); and stroke with PPCS1, SGLDM correlation, and percentage of pixels with gray levels 11 to 20 (PPCS2; echolucency). The area under the curve of the regression-derived predicted probability for AmF, TIA, and stroke was 0.92, 0.82, and 0.85, respectively (all P < .001). Texture analysis can identify carotid plaques associated with a neurological event, improving the diagnostic value of echolucency measures. Texture analyses could be applied to natural history studies.